An infant is rushed back to your resuscitation bay, sats are dropping, the triage nurse knew she needed to bring him right back before even getting a history.
In those first crucial moments in the bay, your differential is broad and your heart rate might be ticking up higher than your patient’s. A bit of history may help narrow your differential. As you run through your ABC’s, think about 3 other A’s that can quickly assist you in making the diagnosis:
- Appearance – Mental status is your key here. Awake, alert, agitated? Probably a good sign, showing you have some time before complete respiratory failure. Lethargic, obtunded? Either they are tiring out from their work of breathing, or something neurologic might be contributing (Think increased intracranial pressure, seizures, toxic ingestion).
- Acuity of onset – Has the patient been sick with URI symptoms for a few days and now is getting sicker (Think bronchiolitis, pneumonia, asthma), or did he rapidly decompensate (Epiglottitis? Foreign body aspiration? Caustic ingestion?).
- Associated symptoms – Were there any preceding symptoms (Think infectious cause that is worsening, also consider sepsis)? Any fevers? In these cases, absolutely no preceding symptoms tends to both narrow my differential but makes me think about some of the even more scary things (Could be croup, but also consider foreign body, anaphylaxis, nonaccidental trauma).
Want to read up on managing a difficult pediatric airway? Dr. Josh Nagler from Boston Children’s Hospital is an expert in this topic, and has published many useful resources:
Miller KA, Goldman MP, Nagler J. Management of the Difficult Airway. Pediatr Emerg Care. 2023 Mar 1;39(3):192-200. doi: 10.1097/PEC.0000000000002916. Epub 2023 Feb 16. PMID: 36790950.
Miller KA, Nagler J. Emergent Airway Management in Pediatrics, in Emily Rose (ed.), Pediatric Emergencies: A Practical, Clinical Guide (New York, 2020; online edn, Oxford Academic, 1 Oct. 2020)
ACEP Webinars (May require login):
Pediatric Emergency Airway Management: A Video-Guided Tour of Cases
Advanced Airway Management in Children: Overcoming Obstacles and Optimizing Opportunities
Dr. Joshua Belfer, MD, is a Pediatric Emergency Medicine physician at the Children’s Hospital of Philadelphia, and is the Founder and Editor-in-Chief of HipPEMcrates. He can be reached at HipPEMcrates@gmail.com.
